“On paper, ECHO looks beautiful and simple. But you have to have somebody that is 100 percent committed.”
Ochsner Health and its Liver Disease Management and Hep C Elimination ECHO programs were part of a study, led by Diffusion Associates and funded by the Robert Wood Johnson Foundation. The purpose of this study was to document and share how ECHO is adopted, implemented and sustained across ECHO hubs and programs in the United States and Canada. This study was separate from, but endorsed by, the ECHO Institute.
This profile is based on transcripts from interviews conducted in November 2020 by R. Sam Larson, PhD, director and founder of Diffusion Associates and Kayla Cole, then director, Center for Quality Improvement at the Maine Medical Center, and lead on Northern New England ECHO Network projects. Cole was one of ten 2020 implementation fellows who worked alongside Diffusion Associates on this study.
Ochsner Health is the largest nonprofit, academic, multi-specialty, health care delivery system in southeast Louisiana. We begin this profile by sharing unique implementation insights from the Ochsner Health and its Liver Disease Management ECHO and Hep C Elimination ECHO programs
ECHO Implementation Insights
ECHO as Internal Training
In a large complex organization such as Ochsner Health, ECHO was used as way to provide training to physicians so that patients experience comparable or standardized care regardless of where they enter the system. ECHO can help build or reinforce institutional norms across a complex system and be a way for physicians to meet each other and build relationships and partnerships.
Lean Staffing Model
One person at half-time was supporting five ECHO programs. This worked for at least two reasons. One, relationships with and existing resources from the ECHO Institute were leveraged. The wheel was not reinvented; there was no time to do that. Two, the staff member at Ochsner was committed to ECHO. As one respondent said to and about this staff member, “ECHO hinges on your dedication.”
Making the Business Case
ECHO was about education and telementoring; this doesn’t mean it can’t also build a business case. ECHO created relationships between specialist and primary care providers. Once you build these relationships, “referrals will come.” Some evidence at Ochsner points to a modest increase in referrals—and while this was not the primary motivator for ECHO, it could help to build a case for additional internal financial support for ECHO.
Ochsner Health did not have a “hub” or a centralized set of resources focused on ECHO. It did have a set of ECHO programs and what held them together was a single staff person who relied on tools and technical support from the ECHO Institute. Ochsner Health was at a juncture where those engaged in ECHO were uncertain it could grow without having some type of a hub-like structure. Growth, including creating a hub, was dependent on building a business case for the ECHO work.
ECHO Model Adoption
Project ECHO was introduced to Ochsner Health (Ochsner) by Shoba Joshi, MD, a hepatologist, and Chrisey Smith, a prescription assistance program coordinator with Ochsner’s Multi-Organ Transplant Institute. Joshi heard about Project ECHO at an HIV management conference and then read an article that Sanjeev Arora, MD, published in the New England Journal of Medicine about Project ECHO. In 2012, Joshi and Smith attended immersion training at the ECHO Institute in Albuquerque where they sat through the Hepatitis C clinic and learned how to conduct an ECHO session.
The Multi-Organ Transplant Institute was the launching point for ECHOs in Ochsner, but as ECHO programs grew in number and as the focus expanded beyond liver and transplant topics, there was a discussion afoot about where this work should be located within the Ochsner system. Claudia Medina, MD, director of international service at Ochsner, said she was asked to help support Smith in pushing ECHO into and across the health system. Medina and Smith both said that push was not easy but it was not without support. As more physicians became aware of the model, the push into the organization became stronger. Medina noted that “you need to have one person that really pushes and pushes and pushes” to generate institutional adoption.
Smith provided administrative support for both programs, as well as three additional ECHO programs. Smith, Joshi, Tyson, and Medina were funded by Ochsner to work on ECHO as part of their position. ECHO work did not have its own distinct budget in Ochsner.
Liver Disease Management ECHO
Part of the decision to adopt Project ECHO for Liver Management was related to the growth of the Ochsner Health system. Ochsner was acquiring hospitals in Louisiana and Mississippi. With this growth came an expansion of the Ochsner provider pool and a need to “provide guidance so providers can learn how to best manage their patients.” Joshi saw ECHO as a means to offer this guidance, primarily to Ochsner providers. Joshi presented ECHO to her department and, with their support, asked for “management approval to do this, because we need to justify what we do.”
The Liver Management ECHO program had been offered for more than seven years. Participants were Ochsner providers from multiple clinics and hospitals. Participants did not present formal cases, though cases sometimes resulted from session questions. This ECHO met monthly and was ongoing.
Hep C Elimination ECHO
Gia Tyson, MD, MPH, a gastroenterologist who specialized in liver care and who had an appointment in the Multi-Organ Transplant Institute, first heard about ECHO when she was a fellow at Baylor University where she attended a presentation by Arora. Tyson became familiar with ECHO at Ochsner because she was a colleague of Joshi’s. Tyson was working with the State Department of Health on a Hep C Elimination initiative. This initiative required increasing the capacity of providers across the state to diagnosis and treat hepatitis. Tyson said, “We needed a way to reach people throughout the state, and Project ECHO was a perfect platform for that.” As part of this larger Hep C Elimination initiative, Tyson developed and implemented, with support from Smith, a Hep C Champions Program – an educational program that included a half-day of training followed by a 12-week Hep C ECHO program. Participants included primary care providers across Louisiana. Participants seeking education and support around HCV treatment were required to present five cases and attend at least 70 percent of the ECHO sessions.
ECHO Model Implementation
The ECHO Model seeks to build a learning community where “all teach, all learn.” This is done by leveraging technology, by sharing best practices, through case-based learning, and using data. We asked respondents to tell us what “all teach, all learn” meant to them. Respondents tended to define it as a “level playing field” where everyone in the group “is willing to teach, to give their experiences” and where they’re learning and teaching through questions and discussion. Joshi told her group, “I’m learning from you just as much as I’m teaching. We are here for a give-and-take. We’re not just here to give, we will also learn from you. So, please, speak up.” Tyson “meets people where they are” by bringing her expertise to them in “different ways; verbally, graphically, PowerPoints, and cases” and then asking participants to “share their experiences, especially as they relate to treating challenging populations.” Smith commented, “We can all learn from each other. We can create networks; we can create relationships with one another.” She also commented that providers were learning from each other. A common theme was that “all teach, all learn” required a non-threatening environment that was created, in part, by experts who shared that they don’t always have every answer to every question and that some questions may be answered better by somebody else.
Creating an “all teach, all learn” culture required work that participants did not see. Medina commented, “On paper, ECHO looks beautiful and simple. But you have to have somebody that is 100 percent committed.” That person at Ochsner was Smith who, Medina said, “is doing all of the behind-the-scenes work, and it’s not an easy thing.” Tyson and Joshi also spoke about the importance of Smith in ensuring that the ECHO was structured to encourage an “all teach, all learn” environment. That included having materials prepared in advance, recruiting fellows, following up on the completion of case forms, and “the specific rules of engagement of Project ECHO that are invaluable.” Smith consulted with Joshi and Tyson in advance of ECHO sessions, sometimes just before the session, to review materials and to recap previous session notes.
The Liver Management ECHO and the Hep C Elimination ECHO programs adapted the ECHO Model to best fit their respective contexts, including the needs and interests of participants. Joshi planed the didactics for the Liver Management ECHO in advance, identifying between 10 to 12 presentations a year. But they sometime made last minute changes because something more important would come up. Joshi typically presented the didactics, though she has invited colleagues to join her or to make presentations. She was hesitant to ask colleagues to present during COVID because it has put more stress on the system and she didn’t want to ask someone else to do extra work. The Liver Management ECHO did not rely on participant cases for case-based learning. Joshi explained that when the ECHO program first started, more than seven years earlier, participants brought cases because there was variance in treatment options. But as treatment for Hep C improved and became easier, participants had less of a need to bring cases to the discussion. Further, she described cases as “going back to your residency and fellowship training when you are expected to present cases. Participants may not want to be in that situation, especially those who have been in practice for a while.” She commented that when participants were new or changing treatments, they were more likely to discuss a case. When cases were presented, they came from the discussion and questions and were not formally presented using a case template even though a template was readily available.
The Hep C Elimination ECHO was part of a larger initiative, and was added to an existing education plan “that fit in line perfectly with the ECHO values and the ECHO model.” The ECHO program was nested within the Hep C Champions program, which was designed for primary care physicians. The program began with a half-day in-person or virtual training session “where we have an in-depth review of hepatitis C, the epidemiology of liver disease management staging, and then get into the treatment of hepatitis C. We go through the algorithms we’ve created as part of the state to help primary providers feel comfortable and confident in treating hepatitis C.” After the half-day session, the ECHO sessions began. They lasted for about three months and met three times per month. Sessions began with a didactic, moved to questions, and then case reviews. To become a Hep C Champion, participants had to attend the half-day training, attend 70 percent of the ECHO sessions, and present five cases, and then pass a culminating exam. It’s not only those who were seeking certification as a champion who joined the program; other “providers looking for education and basic information around hepatitis C, liver disease and then treatment, join. They can interact with someone in real time on a very regular basis if they have questions or obstacles as they are embarking on getting people ready for treatment, starting treatment, and completing treatment.”
Factors Influencing Implementation
Studies of program implementation identify contextual factors that can shape how a program was implemented. These factors include leaders and champions, state and federal policies, funding, partnerships, and internal organizational structures and processes, monitoring for quality and fidelity, and staffing—including how people were trained and the characteristics of the people leading and supporting the program.
Not all of these factors may play a role in how ECHO was implemented here or elsewhere, and some factors were more important than others. Below, we identify factors that emerged during interviews and appear to have the most impact on how Project ECHO was implemented in the Ochsner Health system.
ECHO at Ochsner started in the Multi-Organ Transplant Institute with a focus on liver disease management for providers internal to the system. This worked well for early implementation partly because Joshi championed this work among her immediate colleagues and then with system administrators. Joshi had a portion of Smith’s time that could be used to support ECHO. When Tyson initiated the Hep C Elimination ECHO, she was able to tap into Smith’s expertise. But not all ECHOs fit within the Multi-Organ Transplant Institute and this complicated Smith’s role. She explained, “I’m under the budget of transplant. Now that our ECHOs are growing and some are outside of transplant, it’s hard for our executive leader to advocate for me.” Efforts were underway to find a new organizational location for Ochsner’s expanding ECHO portfolio. The process was slow as Ochsner was a large organization with many people involved in making decisions.
Ochsner had several people championing ECHO in the organization. This included Joshi, Tyson, and Medina. It also included a pediatric hematology and oncology physician who used ECHO to educate residents in Manipal, India, during the increasing uncertainty of the COVID pandemic. Smith was also a champion who provided support to all physicians who “really want to champion ECHO but don’t have protected time, who really want to see health equity change, who really want to see better health care outcomes.” This type of leadership was an essential component of implementation, but it was not sufficient. Organizational leaders who control the use of funds also needed to support ECHO implementation. Hesitancy to commit to ECHO was related to the need for a business case for ECHO. One respondent reflected on a conversation with an administrator who said of ECHO, “This is not making money. Should you be spending your time doing this?” Another respondent indicated that administrators raised a question about “diluting consultation capacity” as providers may not need the services of the experts. The physician emphasized to administrators that ECHO was about education but it was possible that referrals could also result from ECHO. Getting administrators on-board had taken longer than expected, but Medina said, “We’re going to get there. I’m sure about that.”
Training and Leveraging ECHO Institute Resources
With a lean staffing model, leveraging training and existing resources was important for implementation. Smith attended multiple immersion trainings with different physicians and also attended MetaECHO conferences. Medina and Joshi attended immersion training. Smith used ECHO Institute materials shared via Box when starting an ECHO or looking for different ideas or tools. She also worked with her liaison at the ECHO Institute. She described working with her liaison and searching Box to ensure they were doing everything correctly and to learn from ECHO programs similar to Ochsner’s. She used “what had already been created because I am the only person who manages all of the ECHOs. There’s a lot of information in Box. I make sure that I don’t recreate the wheel, which is what sharing the knowledge is all about.”
At the time of this interview, ECHO was integrated into current job roles and responsibilities. ECHO had no distinct budget and external funds were not directly supporting any physician or staff time. While Ochsner was supportive, ECHO work was also being done, at least in part, on personal time—in the evenings, weekends, or days off. As one respondent said, “That’s not time paid for. That comes out of our own pockets.” Gaining additional support from within Ochsner required a business argument as Ochsner, like other health care systems, was funded through clinical work. The Hep C Elimination ECHO had some external funding as this ECHO was part of a larger state-initiated project. These funds were used to provide CME credit for non-Ochsner physicians. The organization supported time to implement ECHOs, but staff did not have the time to work on writing proposals for external funding or complete evaluation or research that might make a stronger business case.
The Hep C Elimination ECHO was part of a larger state initiative to eliminate hepatitis. A former Secretary of Health in Louisiana did “a lot of amazing work and very innovative work” to figure out how to reduce costs and eliminate a significant health threat. A full elimination model was proposed because “we have medications that are highly effective and that don’t require a lot of monitoring because they have a good safety profile.” The former secretary pushed for a subscription model that would keep costs fixed by working with a single pharmaceutical company. For this model to work, the state had to address the lack of specialists and increase the number of primary care providers who could identify and treat hepatitis C. ECHO became the means to educate and certify primary care providers so they could identify and treat hepatitis C. The larger policy environment shaped the implementation of the Hep C Elimination ECHO which, in turn, was shaping the larger policy environment.
ECHO Vision and Sustainability
When asked about a vision for the future of ECHO a consistent theme was one of growth. ECHO growth within the Ochsner system was described as a way to ensure equitable care across a complex health care system that had grown quickly. By expanding ECHO topics and reaching out to more Ochsner providers, patients in the health care system could receive the same treatment if they go to “Ochsner in the north of the state or here at our main campus.”
Growth also extended outside of Ochsner both in terms of participants and in who was leading the ECHO. Tyson talked about reaching out to more providers in the state with the current Hep C ECHO and creating spin-off ECHOs to reach current and additional participants. Joshi commented that ECHO topics and the sponsors for ECHOs “don’t always have to come from Ochsner. They could be from Tulane or LSU or another institution. They can hold their own ECHOs. Overall, then, we can create a healthier population in Louisiana.”
To achieve growth within and outside of Ochsner, respondents talked about the need for a “whole department of ECHO.” This would require moving the support for ECHO out of the Multi-Organ Transplant Institute and finding a home for it. Medina said that this was her goal and vision since day one. It was taking longer than expected to do this but Medina said that they were getting there by cultivating champions in the organization that buy into ECHO. As part of their growth strategy, they were seeking external funds to support the development and implementation of ECHO programs. Creating a budget for ECHO that was a mix of external and internal funds was something Medina hoped to change. A possible new location for this work was in the academic/continuing education division.
Growth also required more staff both in the number of people and the percent of their time that was devoted to ECHO. Smith was providing support to five ECHOs, and ECHO was only part of her role. As the scope of ECHOS extended beyond organ transplant, her role became more challenged because it wasn’t clear who should be advocating or approving of her time to work on other ECHOs. Not having someone “dedicated 100 percent of the time to the program makes it really hard to do all the follow-ups on the referrals” and to work on outcomes and reports and resulted in time being utilized during non-work hours.
Growth required finding ways to support participants’ time. One interviewee said, “Everybody has time constraints and they have to justify what they were doing every hour of the day. And if their time is being spent for something not directly related to their work, then who’s paying for it?” External funds from Medicare, Medicaid, or insurers were sources that could compensate for participants’ time. Because participants were “donating” their time, Joshi and Tyson stressed the need for relevant curriculum and sharing agendas in advance so that the “experience is high yield enough so that participants really want to come back.”
Joshi wanted the Liver Management ECHO to reach more people around the state. This could be achieved by visiting providers and clinics in other parts of the state, but it was a challenge to find the time to do this given the need to focus on clinical work. Tyson’s vision for the future of the Hep C Elimination ECHO was to continue to reach more providers with the existing curriculum, and to deepen the knowledge of those they have already reached through the current ECHO program.
Shoba Joshi, MD
Director, Hepatology Research
Multi-Organ Institute, Ochsner Health
Claudia Medina, MD
Director International Services
Project ECHO, Administrative Coordinator
Gia Tyson, MD, MPH
Chair of Hepatology
Ochsner Health Baton Rouge
Larson, R.S. (2022). Ochsner Health System Project ECHO implementation profile. Diffusion Associates. https://www.diffusionassociates.com/echo.